Earlier this month, the World Medical Association updated the Hippocratic oath to include a statement that it is against medical ethics for doctors to participate in capital punishment. On Tuesday, the Indian Medical Association joined its global counterpart and asked the Medical Council of India to include a statement to this effect in India’s code of medical ethics.

The World Medical Association first adopted its resolution on physician participation in capital punishment in 1981, which it then amended in 2000 and 2008, The resolution states that “it is unethical for physicians to participate in capital punishment, in any way, or during any step of the execution process, including its planning and the instruction and/or training of persons to perform executions.”

The World Medical Association in 2008 had asked all its member bodies which includes the Indian Medical Association to “lobby actively national governments and legislators against any participation of physicians in capital punishment.”

Dr KK Aggarwal, president of the Indian Medical Association, said “By asking doctors to certify if a person is fit enough to be hanged, the government is forcing us to violate our medical ethics. By certifying someone fit, we are pushing them towards execution.”

At the same time, medical ethics experts have raised the question of why the association has decided to raise the issue at this time, especially when it has remained silent on other ethical violations.

The doctor’s role

According to India’s Code of Criminal Procedure, 1898, the method of capital punishment for convicts sentenced to death is hanging. According to the National Crime Records Bureau, 1,303 capital punishment verdicts were announced between 2004 and 2013. Three convicts have been executed during this period.

Doctors have two primary responsibilities in execution. First, they are expected to certify a person “fit to be executed”. Second, doctors are expected to witness the hanging and certify the death of the convict.

When screening someone for fitness for hanging, doctors are supposed to check whether the convict is pregnant if female and look for any diseases. “The reason for certifying someone fit for hanging is to ensure that his death is a result of hanging and nothing else,” said Dr SM Patil, police surgeon with the Maharashtra government.

According to the jail manual, a medical officer (doctor), executive magistrate and superintendent have to sign the execution report which gives details of the name of the prisoner and the time and location of death by hanging. The manual also elaborates on the role of the medical officer in deciding the length of the drop as per the height, weight of the convict.

In 1995, a two judge bench of the Supreme Court while deciding on a petition said that ‘‘a convict shall remain hanging only till he is declared dead by a medical officer.”

In a paper on the role of the medical profession on capital punishment, forensic doctor RK Bansal wrote, “as a result of this little known judgment, a doctor must periodically examine the person after hanging to look for signs of life. If the person is found alive, the doctor is to ask the hangman to continue – to order hanging to death instead of resuscitating.”

Writing in the Indian Journal of Medical Ethics in 2003, human rights lawyer Vijay Hiremath pointed out that death by hanging does not meet standards laid down by the Supreme Court for the execution of death penalty – that it should be as quick and simple as possible, that the act of execution should produce immediate unconsciousness passing quickly into death, that it should be decent and should not involve mutilation.

“There have been several cases reported where hanging has not immediately resulted in a broken neck and thus the convict is left to slowly strangle to death. This strangling results in the convict’s eyes popping almost out of his head, his tongue swelling up and protruding from his mouth. In cases where the neck is in fact broken, the rope often tears large portions of the convict’s flesh and muscle from that side of the face where the noose is. In many cases, the convict will end up urinating on himself and defecating before death. The prisoner remains dangling from the end of the rope for 8-14 minutes before a doctor climbs up a small ladder and listens to his heartbeat with a stethoscope and pronounces him dead.”

— Law commission report proposes lethal injection for the death penalty, Indian Journal of Medical Ethics

Dr Anup Surendranath, director of the Centre on the Death Penalty at National Law University in Delhi, said “The law does not authorise the convict to suffer. The law only authorises death, not a painful death.”

The Centre on the Death Penalty undertakes research on death penalty administration and works to ensure that all death row convicts have adequate legal representation.

In fact, in 2003 the Law Commission suggested moving to lethal injection instead of hanging as the method of execution. This means that a doctor will have a more crucial role in the execution process because he or she will have to administer the injection.

Being ethical or obstructing justice?

Aggarwal and his colleagues have consulted legal experts to understand if there is any statute that binds doctors to participation in capital punishment. “We don’t think there are any legal provisions which can force us to perform executions,” said Aggarwal.

Doctors working as medical officers in jails are expected to follow the jail manual which demands their participation in the execution. “Someone inserted all these duties of doctors in the jail manual. We have to find if it has any legal backing,” said Aggarwal.

However, some doctors do not agree with the World Medical Association’s stand on capital punishment and its support by the Indian Medical Association. “By not participating in executions, doctors will obstruct the course of justice,” said Dr GS Grewal, former president of Punjab Medical Council. “The IMA is undermining the law of the country by refusing to participate in an execution ordered by the court.”

As the Indian Medical Association urges the government to excuse them from the process of execution, legal experts said that it raises questions about the nature of capital punishment.

Members of the Indian Medical Association themselves said that their opposition to the involvement of the medical fraternity in the process of execution does not necessarily mean they do not support capital punishment.

“It is on the government and the courts if they want to execute a convict,” said Aggarwal. “What we are saying is that as doctors, we cannot be a part of it. Medical ethics clearly says that doctors should do no harm.”

Surendranath said that doctors are important stakeholders in the process of execution and that by raising an ethical red flag on the process of execution, doctors are clearly influencing the debate surrounding the torturous nature of capital punishment.

Meanwhile, the Indian Medical Association will wait to see if the Medical Council of India will agree to its request.

“Currently, we cannot take action against any doctor who participates in capital punishment,” agreed Aggarwal. “We want the Medical Council of India to adopt the resolution which will give the resolution some legal backing.”

Patil who works closely with doctors posted in government prisons in Maharashtra said doctors are bound by the jail manual to fulfill their roles in executions. “They are doing their duty,” he said.

Is this really about ethics?

Dr Amar Jesani, editor of the Indian Journal of Medical Ethics pointed out that the Indian Medical Association seems to have woken up to this ethical conflict rather late given that the World Medical Association passed the resolution first in 1981.

Moreover, he said, “If the Indian Medical Association’s opposition is out of real conscientiousness, they should also take up other issues where doctors are involved in human rights violations.”

He indicated that doctors participate in pseudo-scientific procedures like lie detection tests used during interrogation. “There are also instances where doctors are involved in inciting communal violence. The Indian Medical Association should look at these aspects of human right violations too.”

The president of the World Medical Association is Dr Ketan Desai who was elevated to the post in 2016 despite having been arrested in 2010 on bribery charges. Desai also had other corruption cases against him. Several doctors and public health specialists had pointed out the violation of ethics in his appointment.

“Dr Desai’s escalation to the post of the president of the World Medical Association is a result of Indian Medical Association’s lobbying,” said Jesani.

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.

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SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.